Abstract
Purpose
We present our results in the reconstruction of medial orbital wall fractures using a transcaruncular approach.
Methods
Forty-five patients with isolated medial orbital wall fractures underwent reconstruction by transcaruncular approach in our clinic between May 2003 and October 2007, and were followed up for 6 months or more.
Results
Thirty-three males and 12 females were included in this study, with a mean age of 34.9 years. The most common indication for reconstruction were large sized fractures more than 50%. Operations were performed at a mean 11.9 days after trauma. Among 18 patients who had diplopia before the operation, 16 (89%) patients had symptom relief or improvement, and in the 2 patients where diplopia persisted, it did not in primary and down gaze and offered no difficulties in daily activities. Among 34 patients who had enophthalmos before the operation, most (n=30) of the patients had minimal enophthalmos not more than 2 mm, 4 patients had enophthalmos that exceeded 2 mm.
References
1. Dortzbach RK, Kikkava DO. Blowout fracture of orbital floor. American Academy of Ophthalmol. 1995; 204–23.
2. Converse JM, Smith B, Obear MF, Wood-Smith D. Orbital blow out fracture : A ten-year survey. Plast Reconstr Surg. 1967; 39:20–36.
4. Illiff NT. The ophthalmic implications of the correction of late enophthalmos following severe midfacial trauma. Trans Am Ophthalmol Soc. 1991; 89:477–548.
5. Balch KC, Goldberg RA, Green JP, Shorr N. The transcaruncular approach to the medial orbit and ethmoid sinus. Facial Plast Surg Clin North Am. 1998; 6:71–7.
6. Graham SM, Thomas RD, Carter KD, Nerad JA. The transcaruncular approach to the medial orbital wall. Laryngoscope. 2002; 112:986–9.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
7. Cheon HW, Bae J, Lee TS. Transcaruncular approach for reconstruction of old medial orbital wall fracture. J Korean Ophthalmol Soc. 2002; 43:1256–60.
8. Oh JY, Rah SH, Kim YH. Transcaruncular approach to blowout fractures of the medial orbital wall. Korean J Ophthalmol. 2003; 17:50–4.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
9. Davidson TM, Olesen RM, Nahum AM. Medial orbital wall fracture with rectus entrapment. Arch Otolaryngol. 1975; 101:33–5.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
10. Peyman GA, Saunders DR, Goldberg MF. Principle and practice of ophthalmology, Philadelphia, London. Toronto: W. B Saunders Company;1980. 2:p. 437.
11. Cramer LM, Tooze FM, Lerman S. Blowout fracture of the orbit. Br J Plast Surg. 1965; 18:171–9.
12. Fujino T. Experimental blow out fracture of the orbit. Plast Reconstr Surg. 1974; 54:81–2.
13. Brannan PA, Kersten RC, Kulwin DR. Isolated medial orbital wall fractures with medial rectus muscle incarceration. Ophthal Plast Reconstr Surg. 2006; 22:178–83.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
14. Yenice O, Ogüt MS, Onal S, Ozcan E. Conservative treatment of isolated medial orbital wall fractures. Ophthalmic Surg Lasers Imaging. 2006; 37:497–501.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
15. Kroll M, Wolper J. Orbital blow out fracture. Am J Ophthalmol. 1967; 64:1169–72.
16. Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures. Influence of time of repair and fracture size. Ophthalmolology. 1983; 90:1066–70.
17. Harris GJ, Garcia GH, Logani SC. . Orbital blow-out fracture : correlation of preoperative computed tomography and postoperative ocular motility. Trans Am Ophthalmol Soc. 1998; 96:329–47.
18. Jordan DR, Allen LH, White J. . Intervention within days for some orbital floor fractures : the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998; 14:379–90.
19. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group : characterization and management. Ophthalmology. 2000; 107:829–36.
20. Bae JH, Kwak MS. Clinical experience of orbital wall reconstruction using Medpor® barrier sheet implant. J Korean Ophthalmol Soc. 2001; 42:1515–22.
21. Park DW, Kim YD. Porous polyethylene (Medpor®) implants in orbital fracture repairs. J Korean Ophthalmol Soc. 1998; 39:1307–18.
22. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology. 2000; 107:1459–63.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
23. Kim SJ, Jang JW, Lee SY, Lim SJ. Repair of orbital wall fracture using transcaruncular approach. J Korean Ophthalmol Soc. 1999; 40:2054–60.
Figure 1.
Transcaruncular approach in the reconstruction of medial orbital wall fracture; (A) Traction suture in the upper & lower episclera with 6-0 black silk. (B) Conjunctival incision is made with Ellman cautery between the caruncle and semilunar fold. (C) Transcaruncular dissection through the avascluar plane deep to the caruncle in a direction toward the posterior lacrimal crest with straight scissors. (D) The periosteal incision posterior to the posterior lacrimal crest using Ellman cautery. (E) Subperiosteal dissection and herniated orbital soft tissue reduction using malleable retractor and periosteal elevator. (F) Herniated orbital soft tissue is completely reduced and wide exposure of entire fracture site. (G) Medpor® barrier sheet placed to sufficiently cover the defect. (H) Conjuctival wound repairing with continuous suture using 6-0 vicryl.
![jkos-50-1f1.tif](/upload/SynapseXML/0035jkos/thumb/jkos-50-1f1.gif)
Figure 2.
(A) Preoperative CT scan of the patient who has medial orbital wall fracture and muscle displacement into ethmoid sinus. (B) Postoperative CT scan of the same patient. Reconstruction of the wall was done by Medpor® barrier sheet (white arrow).
![jkos-50-1f2.tif](/upload/SynapseXML/0035jkos/thumb/jkos-50-1f2.gif)
Table 1.
Demographic characteristics of patients
Age (years) | Male | Female | Total |
---|---|---|---|
11-20 | 7 | 2 | 9 |
21-30 | 10 | 1 | 11 |
31-40 | 7 | 5 | 12 |
41-50 | 5 | 0 | 5 |
51-60 | 2 | 1 | 3 |
61-70 | 2 | 3 | 5 |
Total | 33 | 12 | 45 |
Table 2.
Causes of fracture
No. of patients (%) | |
---|---|
Assault | 23 (51) |
Traffic accident | 11 (24) |
Sports | 8 (18) |
Slip down | 3 (7) |
Total | 45 (100) |
Table 3.
Indications for fracture repair
No. of patients (%) | |
---|---|
Large fracture > 50% (L) | 15 (33) |
Enophthalmos ≥ 2 mm (E) | 4 (9) |
Clinically significant diplopia (D)∗ | 2 (4) |
E+L | 13 (29) |
D+L | 5 (11) |
D+E | 3 (7) |
D+E+L | 3 (7) |
Total | 45 (100) |
Table 4.
Preoperative and postoperative values of enophthalmos measured by Naugle exophthalmometry
Degree of enophthalmos (mm) | No. of patients (%) | |
---|---|---|
Preoperative | Postoperative | |
E∗=0 | 11 (24) | 20 (44) |
E<1 | 0 (0) | 3 (7) |
1≤ E<2 | 11 (24) | 18 (41) |
2≤ E<3 | 17 (39) | 2 (4) |
3≤ E | 6 (13) | 2 (4) |
Total | 45 (100) | 45 (100) |